EyeWorld Asia-Pacific June 2017 Issue

June 2017 26 EWAP SECONDARY FEATURE Views from Asia-Pacific YAO Ke, MD Professor, Eye Institute of Zhejiang University Eye Center, Second Affiliated Hospital of Zhejiang University, College of Medicine 88 Jiefang Road, Hangzhou 310009, China Tel. no. +86-571-87783897 Fax no. +86-571-87783897 V ery hot topic. The widespread use and overwhelming results of intracameral antibiotics in Europe raise a hot discussion among U.S. surgeons. And it has also aroused attention in China. Recently, the Chinese Cataract Society (CCS) held a board meeting in which perioperative infection prophylaxis in cataract surgery was discussed. The board members of CCS from 24 top Chinese eye centers attended the meeting. Among them, two eye centers have begun to apply intracameral antibiotic injections during cataract surgery following the experience of ESCRS, and concluded some primary positive results. One of them used 1 mg/0.1 ml cefuroxime, and the other used 1 mg/0.1 ml vancomycin. The greatest advantage of intracameral antibiotics is that the antibiotic can be injected directly into the eye, which can then persist at a high concentration inside the eye. Thus, after wound sealing, the antibiotic can kill the bacteria which may have been brought in during the surgery. Nowadays, cefuroxime, vancomycin, and moxifloxacin can be chosen for intracameral injections in China. However, none of them is available as a commercial product used only for intracameral injection. Incorrect dosage or contamination of drugs may happen during the process of drug mixture. This may be the main reason for its limited application. In addition, the Board of CCS investigated the incidence and clinical settings of acute-onset endophthalmitis after cataract surgery at eight eye centers of tertiary care hospitals (201,757 cases) and 30 small- and medium-scale departments (46,185 cases). We found that the incidence of postoperative endophthalmitis was 0.033% in tertiary care hospitals 1 , and 0.11% in small- and medium-scale departments 2 . In the former study, we surprisingly found the incidence in our center was 0% (0/21,031) during the period of 2006–2011, where two types of antibiotics were applied: vancomycin in the irrigating solution (100 mg/L) and tobramycin (4 mg/0.1 ml) subconjunctivally. We considered the combination of vancomycin and tobramycin covered almost all types of organisms that might cause acute postoperative endophthalmitis. However, we noted that recently Witkin reported 36 eyes with postoperative hemorrhagic occlusive retinal vasculitis (HORV) occurring after cataract surgery. These cases were suspected to be caused by a delayed immune reaction after the use of prophylactic intracameral vancomycin. Among these 36 eyes, 34 eyes receive 1 mg/0.1 ml vancomycin injection, and the remaining two eyes of one patient received 20 mg/L vancomycin irrigation. Our center has used the 100 mg/L vancomycin irrigation during cataract surgery regularly in more than 100,000 patients since 2001, and to date no cases have developed HORV after cataract surgery. Therefore, I think that low-concentration intracameral vancomycin irrigation such as we have used seldom causes HORV. Next, the Board of CCS will focus on the results of intracameral antibiotics from the U.S. and other Asia-Pacific countries. Furthermore, we will organize a multicenter study on the effectiveness of intracameral antibiotics, and promote the commercial processing of drugs. For the future, once intracameral antibiotics is approved by the China Food and Drug Administration (CFDA), it may be adopted more widely in China. The Board of CCS also suggests that preoperative povidone iodine application, water-tight incision, and improved surgery technique are very important to the prophylaxes of infection. Reference 1. Yao K, Zhu Y, Zhu Z et al. The incidence of postoperative endophthalmitis after cataract surgery in China: a multicenter investigation of 2006-2011. Br J Ophthalmol. 2013;97(10):1312-7. 2. Zhu Y, Chen X, Yao K, et al. The occurrence rate of acute-onset postoperative endophthalmitis after cataract surgery in Chinese small- and medium-scale departments of ophthalmology. Sci Rep. 2017 Jan;7:40776. Editors’ note: Prof. Yao declared no relevant financial interests. or moxifloxacin and found a significantly decreased incidence of postop endophthalmitis and no association with increased postop adverse events. 3 Another large study in India found a 0.02% endophthalmitis rate among 38,160 eyes of charity patients who received intracameral moxifloxacin prophylaxis, which was one-fourth the rate of the 37,777 eyes that did not receive intracameral moxifloxacin. 4 “I believe there have been sufficient published reports in peer-reviewed journals to support the use intracameral antibiotics, even before there is a commercially available FDA-approved product,” Dr. Henderson said. “U.S. surgeons have the benefit of learning from the experience of our European colleagues. The high acceptance rate and proven efficacy in Europe substantiate the move toward intracameral antibiotics.” Concerns remain Not everyone is convinced that a broad shift to intracameral antibiotics is prudent. Andrzej Grzybowski, MD , professor and chair of ophthalmology, University of Warmia and Mazury, Olsztyn, Poland, said that among the unanswered questions about intracameral antibiotics are why some studies do not show a protective effect from them, why many studies show similar effects from topical antibiotics, and most importantly, which intracameral antibiotics should be used. Dr. Grzybowski noted “there are many arguments against cefuroxime, vancomycin, and Is it time – from page 24